The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73 (6), Page 6859-6863
Evaluation of Pyloric Stenosis Management, Laparoscopic versus Open Pyloromyotomy
Awath Fahim Alsulami1, Abdulrahman Abdullah Alzahrani1, Ahmed Bakr Ibrahim2, Ali Abdulla Almazeedi3, Abdullah Saud Alfaraj3, Asma Mutni Al-Mutairi4, Razan Mohammad S Almuallad5, Maram Mudhhi Alabdali5, Hadeel Taha Alsaadi5, Bodoor Salmi Almotairi6
1- Umm Al- Qura University, 2- King Saud bin Abdulaziz University, 3- Mansoura University, 4- Al-Qassim University, 5- Ibn Sina National College, 6- Taibah University Abstract Background: Hypertrophic pyloric stenosis (HPS) is associated with gastric outlet obstruction that occurs as a result of pylorus muscular layers hypertrophy. HPS is considered as the most common cause of vomiting in infancy that requires surgical intervention. Despite advances in neonatal and surgical care, still there is a debate between the pediatric surgeons about the approach that can provide better outcomes for the patients. Objective: In our paper, we aimed to review the recent randomized clinical trials and reviews that compared between laparoscopic and open pyloromyotomy to assess their outcomes, merits and pitfall of each. Methods: PubMed database was used for articles selection, and the following keys used in the mesh ("Hypertrophic Pyloric Stenosis /management"[Mesh] OR "\ Hypertrophic Pyloric Stenosis /outcomes"[Mesh]) AND ("Mortality/Morbidity"[Mesh]). A total of 12 studies were enrolled into our review according to our inclusion and exclusion criteria. Conclusion: We found that overall Laparoscopic pyloromyotomy procedures were as safe and effective as Open pyloromyotomy procedures for infants with hypertrophic pyloric stenosis. However, there was a trend in the LP group towards shorter time, especially with regard to the full time to feeds, length of stay after surgery, operating time. We think that our findings justify the continued use of laparoscopic pyloromyotomy for the management of infantile hypertrophic pyloric stenosis, and recommend its use in centers with appropriate laparoscopic experience. Key words: pyloric stenosis, management, laparoscopic pyloromyotomy, open pyloromyotomy.
INTRODUCTION Hypertrophic pyloric stenosis (HPS) is may play a role; Ghazwany et al. [4] found that associated with gastric outlet obstruction that the incidence of 2.99/1000 occur in preterm occurs as a result of pylorus muscular layers infants compared to 2.25/1000 in term infants. hypertrophy [1]. HPS is considered as the most Examination of the pylorus itself has revealed common cause of vomiting in infancy that deficiency or abnormality in the nerve cell requires surgical intervention. This condition fiber, decreased levels of nitric oxide was described in 1888 for the first time by synthase,and increased levels of growth factors Hirschprung [2]. Since that time its incidence (insulin-like growth factor and platelet derived has been increasing. Worldwide the incidence growth factor), which, individually or in of HPS is approximately 1–3 per 1,000 live combination, may result in failure of pyloric births, although rates and trends vary markedly relaxation and/or muscle hypertrophy [5]. from region to region [3]. Ghazwany et al. [4] The gold standard management for HPS is estimated the incidence rate in Saudi Arabia to surgical pyloromyotomy, which used to be be 1.4/10 000 live births [3]. HPS is more done via open right upper quadrant or supra- common in males than females (4:1 to 6:1), and umbilical incision. However, with the recent more frequent in preterm infant than full term advances in the medical field, a laparoscopic [5]. technique for pyloromyotomy was introduced Until now the etiologies that stand behind the in 1991, and both techniques are now widely development of HPS is still unclear. Several utilized. theories have been postulated, but none has Despite advances in neonatal and surgical care, been proven. The recent literatures found that still there is a debate between the pediatric HPS is multifactorial, involving genetic surgeons about the approach that can provide predisposition and environmental factors. better outcomes for the patients. In our paper Neonatal hypergastrinemia and gastric we reviewed the recent randomized clinical hyperacidity may play a role [4]. Premature birth trials and reviews that compared between 6859 Received: 13/9/2018 Accepted: 23/9/2018 Evaluation of Pyloric Stenosis Management, Laparoscopic versus Open Pyloromyotomy
laparoscopic and open pyloromyotomy to Hirschprung [2]. Since that time its incidence assess their outcomes, merits and pitfall of has been increasing. Worldwide the incidence each. of HPS is approximately 1–3 per 1,000 live births, although rates and trends vary markedly METHODOLOGY from region to region [3]. Al-Ghazwany et al. [4] Sample estimated the incidence rate in Saudi Arabia to PubMed was chosen as the search database for be 1.4/10 000 live births3. HPS in general occur the articles selection, because it is one of the more commonly in white males which represent major research databases within the suite of a gender and race predilection. In addition, HPS resources that have been developed by the occurrence has a familial presentation in which National Center for Biotechnology Information 15% of male offspring from an affected mother (NCBI). The following keys used for the Mesh developing the disease. ("Hypertrophic Pyloric Stenosis The etiologies that lead to development of HPS /management"[Mesh] OR "\ Hypertrophic are still elusive. Various theories have been Pyloric Stenosis /outcomes"[Mesh]) AND mentioned, but none has been proven. ("Mortality/Morbidity"[Mesh]). Inclusion According to the recent literatures HPS is a criteria, the articles selected were based on the multifactorial, involving genetic predisposition relevance to the project which should and environmental factors. Neonatal include one of the following topics, { hypergastrinemia and gastric hyperacidity may Hypertrophic pyloric stenosis, HPS play a role [9]. Also, they found that premature Management, HPS Outcomes, laparoscopic birth may play a role in HPS development. and open pyloromyotomy & Morbidity}. Infant with HPS almost all of them present Exclusion criteria, all other articles which between 3 weeks and 3 months of age and has didn’t have one of these topics as their primary developed progressively worsening nonbilious end point, or repeated studies. vomiting. HPS can occur in premature infants Analysis as well. A physician should take in mind during No software was used, The data extracted the history taking to ask about the pattern of based on specific form that contain (Title of vomiting because it plays a major role during the study, name of the author, Objective, the diagnosis process. In HPS vomiting is Summary, Results, and Outcomes), these data postprandial and projectile in nature, which were reviewed by the group members to assess occur as a result of progressive and forceful different management plans of CDH, and the contraction of gastric musculature to move the outcomes related. Double revision of each gastric content through the obstructed pylorus. member’s outcomes was applied to ensure the As the condition progress without any validity and minimize errors. intervention blood stained vomiting might be seen as a result of gastritis that occur as a result RESULTS of repetitive emesis. The infant with HPS is We enrolled a total 12 studies according to our always hungry, and ask for food after each inclusion, and exclusion criteria described vomiting. above. 8 of them were a retrospective studies, and the remaining were a randomized clinical As a result of repetitive vomiting, the infant will trials. All of the included study discussed fail to thrive and present with poor nutritional various aspects of pyloric stenosis management status. Also, infants with HPS as a result of poor and outcomes. The studies characteristics are nutrition are at risk of dehydration shown in Table 1. development. With the continuous vomiting, the gastric secretions are lost, which lead to DISCUSSION development of hypokalemic, hypochloremic During infancy, hypertrophic pyloric stenosis metabolic alkalosis that can progress to (HPS) is the most cause of vomiting that paradoxical aciduria as a result of the renal requires a surgical intervention. This condition response to volume contraction and increasing was described in 1888 for the first time by alkalosis.
Table (1): Included studies details.
6860
Awath Alsulami et al.
Study (year) Study design Objectives Outcomes Ref. Hall et al. [6] RCT To compare outcomes after open or Both open and laparoscopic pyloromyotomy are safe 6 laparoscopic pyloromyotomy for the procedures for the management of pyloric stenosis. treatment of pyloric stenosis. However, laparoscopy has advantages over open pyloromyotomy, and we recommend its use in centres with suitable laparoscopic experience. Carrington et al. [7] RCT Cost-effectiveness of laparoscopic LP is a cost-effective alternative to OP as it delivers 7 versus open pyloromyotomy improved clinical outcome at a lower price. Peter et al. [8] RCT To evaluate potential cosmetic Parents of children scored LP scars superior to OP scars. 8 benefits of laparoscopic Surgical scars are almost always identifiable with OP pyloromyotomy over open while the surgical scars associated with LP approach pyloromyotomy invisibility to the observer, appearing similar to patients with no prior abdominal operation. Siddiqui et al. [9] RCT To compare open with laparoscopic There was no difference in operating time, hospital stay, 9 (2012) pyloromyotomies for HPS with or refeeding patterns between open and laparoscopic assessment of parent satisfaction with pyloromyotomy. The complication rates were similar cosmetic results. between the 2 methods. However, long-term cosmetic results were significantly superior in the laparoscopic group. Ali et al. [10] Retrospective To assess the safety and potential Laparoscopic pyloromyotomy (LPM) is as safe as the 10 Cohort study benefits of the laparoscopic Ramstedt open procedure and has the potential benefits of shorter pyloromyotomy using the experience hospital stay and improved cosmesis. of a single surgeon in a district general hospital. Lange et al. [11] Retrospective To clarify whether the laparoscopic There was no difference in the complication rate as 11 Cohort study procedure has any advantages when compared to the open procedure. The recovery time was compared to the open approach. shorter in the laparoscopic group. A superiority of the laparoscopic pyloromyotomy over the open procedure is suggested by the ascertained data. Vegunta et al. [12] Retrospective Our hypothesis was that, with We are able to demonstrate that, with experience, one 12 Cohort study experience, the outcomes of LP will can expect progressive improvement in the outcomes equal or surpass that of open following LP in infants. Our surgery duration and pyloromyotomy (OP). complications in the last 65 cases are better than most published results for OP or LP. Lemoine et al.[13] Retrospective To compare the use of analgesia in The study suggested that UMBP infants might 13 Cohort study Open transumbilical pyloromyotomy experience more postoperative pain in the ward, without (UMBP) and laparoscopic any impact on various outcomes. A prospective study pyloromyotomy (LAP) patients. with a larger sample size should be undertaken to verify these findings. Mahida et al. [14] Retrospective To determine the impact of Compared to laparoscopic pyloromyotomy, open 14 Cohort study laparoscopic versus open pyloromyotomy is independently associated with pyloromyotomy on postoperative a higher likelihood of a prolonged postoperative LOS. length of stay (LOS). Binet et al. [15] Retrospective Make a review of all our LP LP procedure appeared to be as quick as the open 15 Cohort study procedures with an objective procedure. LP procedure causes little pain during the evaluation according to the literature. postoperative period. No wound complications were registered. Costanzo et al. [16] Retrospective To compare postoperative We have demonstrated that post-operative outcomes 16 Cohort study complications and length of stay for after laparoscopic pyloromyotomy are equivalent or infants undergoing laparoscopic superior to an open approach. The minimally invasive versus open pyloromyotomy. approach to pyloromyotomy is a safe and feasible option in the treatment of HPS in infants.
A physician can suspect HPS by a good history abdominal ultrasound as a diagnostic test to taking and physical examination. During the help them in HBS diagnosis. Generally examination, the physician may palpate a accepted guidelines for the diagnosis of HPS by ‘‘olive’’ (the enlarged pylorus) in the ultrasound include a wall thickness of 4 mm and epigastrium, usually just to the right of midline. a pyloric channel length of at least 16 mm. The pylorus is mobile in its superior/inferior The gold standard management for HPS is direction and is palpated more easily with the surgical pyloromyotomy which can be done via stomach empty (after emesis) and the child open or laparoscopic procedure. In our paper quiet. Additionally, physicians can use we reviewed the recent randomized clinical
6861
Evaluation of Pyloric Stenosis Management, Laparoscopic versus Open Pyloromyotomy
trials and reviews that compared between mentioned that LP can provide better outcomes laparoscopic and open pyloromyotomy to for infant with HPS especially if it was done by assess their outcomes, merits and pitfall of an experienced surgeon. Mahida et al. [14], each. determined the impact of laparoscopic versus Open pyloromyotomy (OP), was used for the open pyloromyotomy on postoperative length first time in 1903 by Dent. Subsequently, of stay (LOS), he found OP is independently different surgeons used the extramucosal associated with higher likelihood of a pyloroplasty by dividing the pyloric muscle prolonged postoperative LOS. Binet et al. [15] transversally and leaving the mucosa intact. In found the LP operation time same as OP and LP 1911 Ramstedt was the first one to divide the postoperative pain is little. Costanzo et al. [16] muscle longitudinally. Ramstedt procedure was compared between the two procedures in done through a transverse right upper quadrant postoperative complication and length of abdominal laparotomy. Later on, in 1986, Tan hospital stay. They found that postoperative and Bianchi first described 40 children who complications of LP is the same or superior to underwent pyloromyotomy via a OP, and the minimal invasive approach to circumumbilical incision. According to the pyloromyotomy is safe and practical option for literatures none of these techniques seems to be HPS treatment. Kethman et al. [17] agreed with superior to the other one, except that Costanzo et al. [16] in which LP associated is circumumbilical incision might have a better with lower complications rate compared to OP cosmetic outcomes. and it's safer, effective procedures for HPS in The first laparoscopic pyloromyotomy (LP), centers capable of minimally invasive surgery. was done for the first time in 1990. Since then, Although the number of studies on which our many centers have used this technique conclusion based is small, we found that overall expecting better cosmetic results and faster LP procedures were as safe and effective as OP recovery from surgery. LP is done by using a 3 procedures for infants undergoing mm or 5 mm port in the umbilical fold to hold pyloromyotomy. However, there was a trend in a telescope. Then a capnoperitoneum is the LP group towards shorter time, especially established. After that, another two incisions with regard to the full time to feeds, length of are done in the upper abdomen to insert a 3 mm stay after surgery, operating time, cost- instruments without trocars. Finally, the effectiveness, decreased analgesia hypertrophic muscle fiber are spread with an requirements, and improved parental cosmetic endoscopic spreader in a longitudinal way. satisfaction. Overall, our findings suggest that, Hall et al. [6]. discussed the various outcomes although both procedures are safe, laparoscopy differences between (LP) and (OP), they found has several advantages over open that both had low risk for the management of pyloromyotomy, with almost same pyloric stenosis. However, laparoscopy is postoperative complications. We think that our considered superior over open pyloromyotomy findings justify the continued use of due to short time procedure, full enteral feed laparoscopic pyloromyotomy for the was tolerated and early discharge. Carrington management of infantile hypertrophic pyloric et al. [7] studied the financial aspects of stenosis, and recommend its use in centers with laparoscopic versus open pyloromyotomy, and appropriate laparoscopic experience. found that LP is a cost-effective compared to OP as it delivers improved clinical outcome at REFERENCES a lower price. Peter et al. [8] evaluated the 1. Maheshwai N (2007): Are young infants potential cosmetic benefits of LP over OP; they treated with erythromycin at risk for found that surgical scars are almost always developing hypertrophic pyloric stenosis identifiable with OP while the surgical scars . Arch Dis Child, 2 (3) : 271 – 273 associated with LP approach invisibility to the 2. Mullassery D, Perry D, Goyal A et al. observer, appearing similar to patients with no (2008): Surgical practice for infantile prior abdominal operation. Ali et al. [10] found hypertrophic pyloric stenosis in the United the LP is as safe as OP and have additional Kingdom and Ireland—a survey of benefits of short LOS and cosmetics. Lange et members of the British Association of al. [11] mentioned that there is no difference in Paediatric Surgeons. J Pediatr Surg., complications between two procedures and the 43:1227–1229. LP had shorter recovery time. Vegunta et al. [12]
6862
Awath Alsulami et al.
3. Grant GA and McAleer JJ (1984): 11. Lange R, Rey M & DomÍnguez E (2008): Incidence of infantile hypertrophicpyloric Open vs. laparoscopic pyloromyotomy – a stenosis. Lancet, 1:1177-1183 retrospective analysis. Minimally Invasive 4. Al-Ghazwany S (2012): Infantile Therapy,17:5; 313–317. hypertrophic pyloric stenosis: a single 12. Vegunta RK, Woodland JH, Rawlings institution’s experience. Annals of AL et al. (2007): Practice makes perfect: Pediatric Surgery, 8:39–41 progressive improvement of laparoscopic 5. Rogers IM (1997): The enigma of pyloric pyloromyotomy results, with experience. J stenosis. Some thoughts on the aetiology. Laparoendosc Adv Surg Tech Acta Paediatr., 86:6-13. A.,18(1):152-156. 6. Hall NJ, Pacilli M, Eaton S et al. (2009): 13. Lemoine C, Paris C, Morris M et al. Recovery after open versus laparoscopic (2011): Open transumbilical pyloromyotomy for pyloric stenosis: a pyloromyotomy: is it more painful than the double-blind multicentre randomised laparoscopic approach? J Pediatr Surg., controlled trial. Lancet, 31;373(9661):390- 46(5):870-3. 8. 14. Mahida JB (2016): Laparoscopic 7. Carrington EV, Hall NJ, Pacilli M et al. pyloromyotomy decreases postoperative (2012): Cost-effectiveness of laparoscopic length of stay in children with hypertrophic versus open pyloromyotomy. J Surg Res., pyloric stenosis, J Pediatr Surg., 51(9): 178(1):315-20. 1436 – 1439. 8. Peter SD, Acher CW, Shah SR et al. 15. Binet A, Klipfel C, Meignan P et al. (2016): Parental and Volunteer Perception (2018): Laparoscopic pyloromyotomy for of Pyloromyotomy Scars: Comparing hypertrophic pyloric stenosis: a survey of Laparoscopic, Open, and Nonsurgical 407 children. Pediatr Surg Int., 34(4):421- Volunteers. J Laparoendosc Adv Surg Tech 426. A., 26(4):305-308. 16. Costanzo CM, Vinocur C and Berman L 9. Siddiqui S, Heidel RE, Angel CA et al. (2018): Postoperative outcomes of open (2012): Pyloromyotomy: randomized versus laparoscopic pyloromyotomy for control trial of laparoscopic vs open hypertrophic pyloric stenosis. J Surg Res., technique. J Pediatr Surg., 47(1):93-98. 224:240-244. 10. Ali A, Tripuraneni G, Velmurugan S et 17. Kethman WC, Harris AH, Hawn MT et al. (2008): Laparoscopic pyloromyotomy al. (2018): Trends and surgical outcomes of is both safe and effective in a district laparoscopic versus open hospital. Surg Endosc., 22(1):151-3. pyloromyotomy. Surg Endosc., 32(7):3380-3385.
6863